Author
HUSEBO B.S.; BALLARD C.; AARSLAND D.;
Pain treatment of agitation in patients with dementia: a systematic review
Journal citation/publication details
International Journal of Geriatric Psychiatry, 26(10), October 2011, pp.1012-1018.
Summary
The evidence for this systematic review was limited to only three randomised controlled trials, two of which included small sample sizes. The results were inconsistent and did not support the treatment of agitation in dementia patients with pain management. The need for further controlled studies in larger patient populations is emphasised.
Context
Agitation, one of the three main syndromes causing behavioural and psychiatric symptoms in patients with dementia, can cause great distress to both the patient and carers. One of the causes of agitation may be pain, which is frequently associated with advancing age and is difficult to recognise in dementia patients with limited capacity for communication. The aim of this paper was to systematically review evidence of ‘the effect of pain management on agitation or other related behavioural changes in people with dementia’.
Methods
What sources were searched?
PubMed and the Cochrane databases were searched from 1992 to 2010, in May 2010, by the first author. The reference lists of relevant papers were examined for further studies.
What search terms/strategies were used?
The search terms used were: dementia, agitation, aggression, depression, behavioural disturbances, BPSD, pain, pain assessment, pain treatment, pain management, and analgesics. Details of specific search strategies are not included.
What criteria were used to decide on which studies to include?
Only prospective studies of pain reduction which included patients with dementia, a control condition, and agitation or other related behavioural disturbances as outcome measures, were eligible. The articles were limited to those published in English or German.
Who decided on their relevance and quality?
The process of study selection is not described and there is no indication that study quality was formally assessed.
How many studies were included and where were they from?
Of the 1,192 potentially relevant studies identified: 812 did not include an assessment of behavioural disturbance, and 343 were excluded for the use of non-validated instruments. Only seven of the remaining 37 publications focused on pain medication. Four of the seven were not controlled or randomised, leaving three studies for inclusion in the review. All of the studies were carried out in the USA.
How were the study findings combined?
This is a narrative review in which each of the three included studies are summarised separately.
Findings of the review
All three studies were double-blind controlled trials. Two trials had fewer than 50 participants. Findings were inconsistent.
One trial of the effect of opioids on agitation in severe dementia reported no significant effect, although significantly lower agitation without sedation was reported for a subgroup of patients aged 85 years and older. A study of acetaminophen on behaviour, emotional wellbeing, and the use of psychotropic medication in patients with moderate to severe dementia found no significant effect on any of the main outcomes, but benefits related to social interaction and general activity were noted. The third study of a stepwise protocol found that the administration of analgesics was associated with less discomfort and a reduction in behavioural symptoms.
Authors' conclusions
‘Only three small cross-over RCT studies exploring the effect of pain management on agitation in patients with dementia were identified. The results did not support the hypothesis that pain management improves agitation.’
Implications for policy or practice
None are discussed.